Advertisement

Fertility Counseling for Transgender Adolescents: A Review

      Abstract

      International guidelines in transgender health recommend fertility counseling before the commencement of puberty suppression, estrogen, or testosterone, given the potential for these treatments to impair fertility. However, these recommendations provide little actual guidance to clinicians. Consequently, differences in knowledge and attitudes may lead to clinicians adopting different approaches and goals in the fertility counseling they provide. This review draws attention to the disparity between the rates of desire for genetic parenthood among transgender individuals and the actual rates of fertility preservation (FP) and examines different factors in fertility counseling that affect clinical practice and contribute to this disparity. These factors include how a lack of strong evidence—for the effects of hormone therapy on future fertility and success rates of some FP options—impacts upon counseling, transgender peoples' experiences of fertility counseling and preservation, consideration of a young person's developmental stage and the roles of parents and clinicians in the decision-making process, considerations shaping transgender adolescents' decisions to preserve fertility, and access barriers to FP. In doing so, this review highlights the complexities and issues that clinicians must consider when providing fertility counseling to transgender adolescents and—in part—helps to address the lack of detailed clinical guidelines in this area.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Adolescent Health
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Telfer M.M.
        • Tollit M.A.
        • Pace C.C.
        • et al.
        Australian standards of care and treatment guidelines for transgender and gender diverse children and adolescents.
        Med J Aust. 2018; 209: 132-136
        • Coleman E.
        • Bockting W.
        • Botzer M.
        • et al.
        Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7.
        Int J Transgenderism. 2012; 13: 165-232
        • Hembree W.C.
        • Cohen-Kettenis P.T.
        • Gooren L.
        • et al.
        Endocrine treatment of gender-dysphoric/gender-incongruent persons: An endocrine Society clinical practice guideline.
        J Clin Endocrinol Metab. 2017; 102: 3869-3903
        • Knudson G.
        • De Sutter P.
        Fertility options in transgender and gender diverse adolescents.
        Acta Obstet Gynecol Scand. 2017; 96: 1269-1272
        • Johnson E.K.
        • Finlayson C.
        Preservation of fertility potential for gender and sex diverse individuals.
        Transgend Health. 2016; 1: 41-44
        • Wierckx K.
        • Van Caenegem E.
        • Pennings G.
        • et al.
        Reproductive wish in transsexual men.
        Hum Reprod. 2012; 27: 483-487
        • Bangalore Krishna K.
        • Fuqua J.S.
        • Rogol A.D.
        • et al.
        Use of gonadotropin-releasing hormone analogs in children: Update by an international consortium.
        Horm Res Paediatr. 2019; 91: 357-372
        • Carel J.C.
        • Eugster E.A.
        • Rogol A.
        • et al.
        Consensus statement on the use of gonadotropin-releasing hormone analogs in children.
        Pediatrics. 2009; 123: E752-E762
        • Light A.D.
        • Obedin-Maliver J.
        • Sevelius J.M.
        • et al.
        Transgender men who experienced pregnancy after female-to-male gender transitioning.
        Obstet Gynecol. 2014; 124: 1120-1127
        • Lu C.C.
        • Steinberger A.
        Effects of estrogen on human seminiferous tubules: Light and electron microscopic analysis.
        Am J Anat. 1978; 153: 1-13
        • Nahata L.
        • Chen D.
        • Moravek M.B.
        • et al.
        Understudied and under-reported: Fertility issues in transgender youth—A narrative review.
        J Pediatr. 2019; 205: 265-271
        • Schneider F.
        • Kliesch S.
        • Schlatt S.
        • et al.
        Andrology of male-to-female transsexuals: Influence of cross-sex hormone therapy on testicular function.
        Andrology. 2017; 5: 873-880
        • Venizelos I.D.
        • Paradinas F.J.
        Testicular atrophy after oestrogen therapy.
        Histopathology. 1988; 12: 451-454
        • Leavy M.
        • Trottmann M.
        • Liedl B.
        • et al.
        Effects of elevated beta-estradiol Levels on the functional morphology of the testis - new insights.
        Sci Rep. 2017; 7: 39931
        • Lübbert H.
        • Leo-Roßberg I.
        • Hammerstein J.
        Effects of ethinyl estradiol on semen quality and various hormonal parameters in a eugonadal male.
        Fertil Sterility. 1992; 58: 603-608
        • Schneider F.
        • Neuhaus N.
        • Wistuba J.
        • et al.
        Testicular functions and clinical characterization of patients with gender dysphoria (GD) undergoing sex reassignment surgery (SRS).
        J Sex Med. 2015; 12: 2190-2200
        • Schulze C.
        Response of the human testis to long-term estrogen treatment: Morphology of Sertoli cells, Leydig cells and spermatogonial stem cells.
        Cell And Tissue Res. 1988; 251: 31-43
        • Armuand G.M.
        • Wettergren L.
        • Rodriguez-Wallberg K.A.
        • et al.
        Desire for children, difficulties achieving a pregnancy, and infertility distress 3 to 7 years after cancer diagnosis.
        Support Care Cancer. 2014; 22: 2805-2812
        • Valentine S.E.
        • Shipherd J.C.
        A systematic review of social stress and mental health among transgender and gender non-conforming people in the United States.
        Clin Psychol Rev. 2018; 66: 24-38
        • De Sutter P.
        • Verschoor A.
        • Hotimsky A.
        • et al.
        The desire to have children and the preservation of fertility in transsexual women: A survey.
        Int J Transgenderism. 2002; 6
        • Nahata L.
        • Tishelman A.C.
        • Caltabellotta N.M.
        • et al.
        Low fertility preservation utilization among transgender youth.
        J Adolesc Health. 2017; 61: 40-44
        • Chiniara L.N.
        • Viner C.
        • Palmert M.
        • et al.
        Perspectives on fertility preservation and parenthood among transgender youth and their parents.
        Arch Dis Child. 2019; 104: 739-744
        • Auer M.K.
        • Fuss J.
        • Nieder T.O.
        • et al.
        Desire to have children among transgender people in Germany: A cross-sectional multi-center study.
        J Sex Med. 2018; 15: 757-767
        • Wierckx K.
        • Stuyver I.
        • Weyers S.
        • et al.
        Sperm freezing in transsexual women.
        Arch Sex Behav. 2012; 41: 1069-1071
        • Chen D.
        • Simons L.
        • Johnson E.K.
        • et al.
        Fertility preservation for transgender adolescents.
        J Adolesc Health. 2017; 61: 120-123
        • Brik T.
        • Vrouenraets L.
        • Schagen S.E.E.
        • et al.
        Use of fertility preservation among a cohort of transgirls in the Netherlands.
        J Adolesc Health. 2019; 64: 589-593
        • Tishelman A.C.
        • Sutter M.E.
        • Chen D.
        • et al.
        Health care provider perceptions of fertility preservation barriers and challenges with transgender patients and families: Qualitative responses to an international survey.
        J Assist Reprod Genet. 2019; 36: 579-588
        • Hembree W.C.
        Guidelines for pubertal suspension and gender reassignment for transgender adolescents.
        Child Adolesc Psychiatr Clin N Am. 2011; 20: 725-732
        • Light A.D.
        • Zimbrunes S.E.
        • Gomez-Lobo V.
        Reproductive and obstetrical care for transgender patients.
        Curr Obstetrics Gynecol Rep. 2017; 6: 149-155
        • De Roo C.
        • Lierman S.
        • Tilleman K.
        • et al.
        Ovarian tissue cryopreservation in female-to-male transgender people: Insights into ovarian histology and physiology after prolonged androgen treatment.
        Reprod Biomed Online. 2017; 34: 557-566
        • Lierman S.
        • Tilleman K.
        • Braeckmans K.
        • et al.
        Fertility preservation for trans men: Frozen-thawed in vitro matured oocytes collected at the time of ovarian tissue processing exhibit normal meiotic spindles.
        J Assisted Reprod Genet. 2017; 34: 1449-1456
        • Charter R.
        • Ussher J.M.
        • Perz J.
        • et al.
        The transgender parent: Experiences and constructions of pregnancy and parenthood for transgender men in Australia.
        Int J Transgenderism. 2018; 19: 64-77
        • Adeleye A.J.
        • Reid G.
        • Kao C.N.
        • et al.
        Semen parameters among transgender women with a history of hormonal treatment.
        Urology. 2019; 124: 136-141
        • Mineur P.
        • De Cooman S.
        • Hustin J.
        • et al.
        Feminizing testicular Leydig cell tumor: Hormonal profile before and after unilateral orchidectomy.
        J Clin Endocrinol Metab. 1987; 64: 686-691
        • Gabrilove J.L.
        • Nicolis G.L.
        • Mitty H.A.
        • et al.
        Feminizing interstitial cell tumor of the testis: Personal observations and a review of the literature.
        Cancer. 1975; 35: 1184-1202
        • Chen D.
        • Bernardi L.A.
        • Pavone M.E.
        • et al.
        Oocyte cryopreservation among transmasculine youth: A case series.
        J Assist Reprod Genet. 2018; 35: 2057-2061
        • Chen D.
        • Simons L.
        Ethical considerations in fertility preservation for transgender youth: A case illustration.
        Clin Pract Pediatr Psychol. 2018; 6: 93-100
        • De Roo C.
        • Tilleman K.
        • T'Sjoen G.
        • et al.
        Fertility options in transgender people.
        Int Rev Psychiatry. 2016; 28: 112-119
        • Duncan F.E.
        Egg quality during the pubertal transition-is youth all it's cracked up to be?.
        Front Endocrinol (Lausanne). 2017; 8: 226
        • Hamada A.
        • Kingsberg S.
        • Wierckx K.
        • et al.
        Semen characteristics of transwomen referred for sperm banking before sex transition: A case series.
        Andrologia. 2015; 47: 832-838
        • Demeestere I.
        • Simon P.
        • Dedeken L.
        • et al.
        Live birth after autograft of ovarian tissue cryopreserved during childhood.
        Hum Reprod. 2015; 30: 2107-2109
        • Moreno I.
        • Miguez-Forjan J.M.
        • Simon C.
        Artificial gametes from stem cells.
        Clin Exp Reprod Med. 2015; 42: 33-44
        • von Doussa H.
        • Power J.
        • Riggs D.W.
        Imagining parenthood: The possibilities and experiences of parenthood among transgender people.
        Cult Health Sex. 2015; 17: 1119-1131
        • Armuand G.
        • Dhejne C.
        • Olofsson J.I.
        • et al.
        Transgender men's experiences of fertility preservation: A qualitative study.
        Hum Reprod. 2017; 32: 383-390
        • Mitu K.
        Transgender reproductive choice and fertility preservation.
        AMA J Ethics. 2016; 18: 1119-1125
        • Kyweluk M.A.
        • Sajwani A.
        • Chen D.
        Freezing for the future: Transgender youth respond to medical fertility preservation.
        Int J Transgenderism. 2018; 19: 401-416
        • Medicare
        Medicare item #16519 processed from January 2013 to October, 2018.
        (Available at:) (Accessed March 24, 2019)
        • Tornello S.L.
        • Bos H.
        Parenting intentions among transgender individuals.
        LGBT Health. 2017; 4: 115-120
        • Maxwell S.
        • Noyes N.
        • Keefe D.
        • et al.
        Pregnancy outcomes after fertility preservation in transgender men.
        Obstet Gynecol. 2017; 129: 1031-1034
        • Riggs D.W.
        Transgender men's self-representations of bearing children post-transition.
        in: Green F. Friedman M. Chasing rainbows. Demeter Press, Toronto2013: 62-71
        • James-Abra S.
        • Tarasoff L.A.
        • Green D.
        • et al.
        Trans people's experiences with assisted reproduction services: A qualitative study.
        Hum Reprod. 2015; 30: 1365-1374
        • Dickey L.M.
        • Ducheny K.M.
        • Ehrbar R.D.
        Family creation options for transgender and gender nonconforming people.
        Psychol Sex Orientation Gend Divers. 2016; 3: 173-179
        • Goldman R.H.
        • Kaser D.J.
        • Missmer S.A.
        • et al.
        Fertility treatment for the transgender community: A public opinion study.
        J Assist Reprod Genet. 2017; 34: 1457-1467
        • Chen D.
        • Matson M.
        • Macapagal K.
        • et al.
        Attitudes toward fertility and reproductive health among transgender and gender-nonconforming adolescents.
        J Adolesc Health. 2018; 63: 62-68
        • Strang J.F.
        • Jarin J.
        • Call D.
        • et al.
        Transgender youth fertility attitudes questionnaire: Measure development in nonautistic and autistic transgender youth and their parents.
        J Adolesc Health. 2018; 62: 128-135
        • Nahata L.
        • Campo-Engelstein L.T.
        • Tishelman A.
        • et al.
        Fertility preservation for a transgender teenager.
        Pediatrics. 2018; 142: e20173142
        • Chen D.
        • Kolbuck V.D.
        • Sutter M.E.
        • et al.
        Knowledge, practice behaviors, and perceived barriers to fertility care among providers of transgender healthcare.
        J Adolesc Health. 2019; 64: 226-234
        • Campo-Engelstein L.
        • Chen D.
        • Baratz A.B.
        • et al.
        The ethics of fertility preservation for pediatric patients with differences (disorders) of sex development.
        J Endocr Soc. 2017; 1: 638-645
        • Abel B.S.
        Hormone treatment of children and adolescents with gender dysphoria: An ethical analysis.
        Hastings Cent Rep. 2014; 44: S23-S27
        • Finlayson C.
        • Johnson E.K.
        • Chen D.
        • et al.
        Proceedings of the working group session on fertility preservation for individuals with gender and sex diversity.
        Transgend Health. 2016; 1: 99-107
        • Bartholomaeus C.
        • Riggs D.W.
        Transgender and non-binary Australians' experiences with healthcare professionals in relation to fertility preservation.
        Cult Health Sex. 2020; 22: 129-145
        • Hudson J.
        • Nahata L.
        • Dietz E.
        • et al.
        Fertility counseling for transgender AYAs.
        Clin. 2018; 6: 84-92
        • Light A.
        • Wang L.F.
        • Zeymo A.
        • et al.
        Family planning and contraception use in transgender men.
        Contraception. 2018; 98: 266-269
        • Broughton D.
        • Omurtag K.
        Care of the transgender or gender-nonconforming patient undergoing in vitro fertilization.
        Int J Transgenderism. 2017; 18: 372-375
        • Weiner B.A.
        • Zinner L.
        Attitudes toward straight, gay male, and transsexual parenting.
        J Homosex. 2015; 62: 327-339
        • Green R.
        Parental alienation syndrome and the transsexual parent.
        Int J Transgenderism. 2006; 9: 9-13
        • T'Sjoen G.
        • Van Caenegem E.
        • Wierckx K.
        Transgenderism and reproduction.
        Curr Opin Endocrinol Diabetes Obes. 2013; 20: 575-579
        • Brothers D.
        • Ford W.C.
        Gender reassignment and assisted reproduction: An ethical analysis. Bristol Centre for Reproductive Medicine Ethics Advisory Committee.
        Hum Reprod. 2000; 15: 737-738
        • Chiland C.
        • Clouet A.M.
        • Golse B.
        • et al.
        A new type of family: Transmen as fathers thanks to donor sperm insemination. A 12-year follow-up exploratory study of their children.
        Neuropsychiatrie de l'Enfance et de l'Adolescence. 2013; 61: 365-370
        • Wallace S.A.
        • Blough K.L.
        • Kondapalli L.A.
        Fertility preservation in the transgender patient: Expanding oncofertility care beyond cancer.
        Gynecol Endocrinol. 2014; 30: 868-871
        • Murphy T.F.
        The ethics of helping transgender men and women have children.
        Perspect Biol Med. 2010; 53: 46-60
        • De Sutter P.
        Gender reassignment and assisted reproduction: Present and future reproductive options for transsexual people.
        Hum Reprod. 2001; 16: 612-614
        • Riggs D.W.
        • Power J.
        • von Doussa H.
        Parenting and Australian trans and gender diverse people: An exploratory survey.
        Int J Transgenderism. 2016; 17: 59-65
        • Jones C.A.
        • Reiter L.
        • Greenblatt E.
        Fertility preservation in transgender patients.
        Int J Transgenderism. 2016; 17: 76-82
        • Riggs D.W.
        An examination of “just in case” arguments as they are applied to fertility preservation for transgender people.
        in: Mackie V. Ferber S. Marks N. The body and the globe: From IVF to global reproductive industry. Lexington Books, New York2018
        • Johnson E.K.
        • Chen D.
        • Gordon E.J.
        • et al.
        Fertility-related care for gender and sex diverse individuals: A provider needs-assessment survey.
        Transgend Health. 2016; 1: 197-201
        • Tarasoff L.A.
        • Epstein R.
        • Green D.C.
        • et al.
        Using interactive theatre to help fertility providers better understand sexual and gender minority patients.
        Med Humanit. 2014; 40: 135-141
        • Dharamsi S.
        • Ho A.
        • Spadafora S.M.
        • et al.
        The physician as health advocate: Translating the quest for social responsibility into medical education and practice.
        Acad Med. 2011; 86: 1108-1113

      Linked Article

      • Commemorating Pride: Reflecting on Progress and Continuing to Advocate for Gender Diverse and Sexual Minority Youth
        Journal of Adolescent HealthVol. 66Issue 6
        • Preview
          Lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) Pride Month is marked with parades, demonstrations, workshops, and other events to recognize the local and global impact of LGBTQ individuals. This month also reminds us to honor those within the LGBTQ community who we have lost and reflect on our past and present struggles for human rights. Our history is rich in examples of how the LGBTQ community has fought for these rights: Compton Cafeteria Riots in San Francisco, Stonewall Riots in New York, demonstrations by the AIDS Coalition to Unleash Power to prompt governmental response for the AIDS epidemic, and the fight for same-sex marriage.
        • Full-Text
        • PDF